Email Updates
September 23, 2020 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, and more. Past issues of the PSNet Weekly Update are available to browse. WebM&M presents current and past monthly issues of Cases & Commentaries and Perspectives on Safety.
Finn KM, Halvorsen AJ, Chaudhry S, et al. J Gen Intern Med. 2020;35:3205-3209.
This article reports on results from a 2017 survey of internal medicine residency program directors’ support for flexible work hours introduced by the Accreditation Committee on Graduate Medical Education (ACGME) based on trial results. Although the majority of programs supported the ACGME work hour flexibility, only one quarter of programs introduced longer work hours.
Bittman J, Nijjar AP, Tam P, et al. J Patient Saf. 2020;16:e169-e173.
This study found that two early warning scores – the Modified Early Warning Score (MEWS) and the National Early Warning Score (NEWS) – can predict patients at risk of deterioration and who will need to be seen by a physician overnight. The authors conclude that use of such early warning scores may be useful for improving handoffs and resource allocation for overnight care.
Auerbach AD, O'Leary KJ, Greysen SR, et al. J Hosp Med. 2020;15:483-488.
Based on a survey of hospital medicine groups at academic medical centers in the United States (conducted April 2020), the authors of this study characterized inpatient adaptations to care for non-ICU COVID-19 patients. Sites reported rapid expansion of respiratory isolation units (RIUs – dedicated units for patients with known or suspected COVID-19), an emphasis on telemedicine for patient evaluation, and implementation of approaches to minimize room entry. In addition, nearly half of responding sites reported diagnostic errors involving COVID-19 (missing non-COVID-19 diagnoses among infected patients and missing COVID-19 diagnoses in patients admitted for other reasons).
Joseph R, Lee SW, Anderson SV, et al. Am J Health-System Pharm. 2020;77:1231-1236.
This observational study assessed the impact of smart infusion pumps and electronic health record (EHR) interoperability in intensive care settings. Findings indicate that interoperability led to an increase in documentation of rate changes, a decrease in alerts triggered, and increased perceptions of clinical data accuracy and efficiency among pharmacists.
Lerner JE, Martin JI, Gorsky GS. Sex Res Social Pol. 2020;18:409-426.
This study used national survey data to examine avoidance of healthcare services among transgender, gender nonconforming, and non-binary people. Researchers found that nearly one quarter of respondents reported not seeking healthcare when necessary because they anticipated being disrespected or mistreated by healthcare professionals. Previous experience with certain discriminatory behavior such as invasive questions, refusal of care, verbal harassment, as well as cost and needing to educate providers, were strong predictors of healthcare avoidance.
Braun B, Chitavi SO, Perkins KM, et al. Jt Comm J Qual Patient Saf. 2020;46:531-541.
In this retrospective review of ambulatory care infection prevention and control (IPC) breaches reported to state health departments, the authors observed 5% rate of breaches and found that common breaches involved sterilization and disinfection of reusable devices, device reprocessing, and IPC infrastructure. These and other breaches highlight opportunities for additional training, leadership oversight, and resource investment.
Bergerød IJ, Braut GS, Wiig S. J Patient Saf. 2020;16:e205-e210.
Based on qualitative data from healthcare professionals and managers at two Norwegian hospitals, this study examined how next-of-kin in cancer care play a role in organizational resilience. Findings show that next-of-kin complement healthcare professionals in the four “potentials” considered essential for resilient performance: potential to respond, potential to monitor, potential to learn, and potential to anticipate.
Mills PD, Soncrant C, Gunnar W. BMJ Qual Saf. 2021;30:567-576.
This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.
Pestian T, Thienprayoon R, Grossoehme D, et al. Pediatr Qual Saf. 2020;5:e328.
The authors used qualitative data to evaluate parental perspectives of quality in pediatric home-based hospice and palliative care (HBHPC) programs, and how parents define “safe care” in the home. Thematic analysis identified eight domains of safety prioritized by patients, including an emphasis on the safety of the physical environment, medication safety, maintaining comfort and preventing harm, and trust in the HBHPC caregivers.
Self WH, Tenforde MW, Stubblefield WB, et al. MMWR Morb Mortal Wkly Rep. 2020;69:1221-1226.
This study examined the prevalence and risk factors for COVID-19 infection among frontline healthcare personnel who work with COVID-19 patients. Serum specimens were collected from a convenience sample of 3,248 frontline personnel between April 3 and June 19, 2020. Six percent (6%) tested positive for SARS-CoV-2 antibodies; a high proportion of these individuals did not suspect that they had been previously infected. This study highlights the role that asymptomatic COVID-19 infections play and authors suggest that enhanced screening and universal use of face coverings in hospitals are two strategies to reduce COVID-19 transmissions in healthcare settings.
Mamede S, Hautz WE, Berendonk C, et al. Acad Med. 2020;95:1223-1229.
This study explored the benefits of reflection on diagnostic errors among internal medicine physicians in Switzerland, and found that diagnostic accuracy increased significantly between the initial diagnosis and the final diagnosis reached after reflection, regardless of the type of reflection used.
Fink BC, Uyttebrouck O, Larson RS. J Law Med Ethics. 2020;48:249-258.
The overprescribing of opiates is a known contributor to the opioid epidemic. This essay describes governmental action taken to adjust prescribing patterns, their effect, and strategies to increase the impact of these actions on opioid misuse and patient harm.
Oliveira J. e Silva L, Vidor MV, Zarpellon de Araújo V, et al. Mayo Clin Proc. 2020;95:1842-1844.
This article discusses the threat that the “flexibilization” of science has played during the COVID-19 pandemic, defined as the loosening of methodological standards leading to low-quality studies, and resulting in unreliable data and anecdotal evidence.
Phillips JM, Stalter AM. J Contin Educ Nurs. 2020;51:402-411.
Focusing on nurses and nurse educators, this article emphasizes systems thinking (a way of viewing, communicating, and understanding relationships that determine the functioning of systems) and the use of the systems awareness model (SAM) for managing the COVID-19 in health systems.
Cantey C. J Nurs Pract. 2020;16:582-585.
This article discusses cognitive decision processes and biases, and their consequences on clinical decision making by nurse practitioners. The authors present several clinical examples of diagnostic error and discuss strategies to avoid future errors.
Eng DM, Schweikart SJ. AMA J Ethics. 2020;22(9):e779-e783.
The recognition that humans err and the situation of response to error in a constructive and nonpunitive light are central to achieving safe patient care. This article discusses how implementation of just culture principles can assign accountability appropriately while encouraging disclosure and improvement when mistakes occur.
Kern-Goldberger AR, Adelman JS, Applebaum JR, et al. Obstet Gynecol. 2020;136:161-166.
This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn pairs and discusses the unique threat the postpartum setting presents to electronic order safety. The article highlights opportunities for systems improvement.
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Edmonton, Alberta; Canadian Patient Safety Institute: 2020. ISBN: 9781926541846.
There is a substantive evidence base of practices that can be deployed to improve patient safety. This guide provides direction for teams to translate knowledge that aids in adapting effective tactics and strategies such as assessments to achieve desired and lasting patient harm reduction.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute care edition. September 10, 2020;25(18)
This alert discusses medication errors that have been reported to the Food and Drug Administration involving the preparation, administration, and storage of two formulations of the investigational COVID-19 treatment remdesivir. Recommendations to guide safe practice include use of standard order sets and dosing clarifications.
Newspaper/Magazine Article
Ramaswamy SV. Rockland/Westchester Journal News. September 9, 2020.
Implicit and explicit biases affect many facets of the health care delivery system. This story shares African-American patient experiences with bias that reduced the safety of maternity care.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Benjamin Stripe, MD, FACC, FSCAI and Dahlia Zuidema, Pharm.D, BC-ADM, CDCES |
A 44-year old man with hypertension and diabetes was admitted with an open wound on the ball of his right foot that could be probed to the bone and evidence of diabetic ketoacidosis. Over the course of the hospitalization, he had ongoing hypokalemia, low magnesium levels, an electrocardiogram showing a prolonged QT interval, ultimately leading to cardiac arrest due to torsades de pointes (an unusual form of ventricular tachycardia that can be fatal if left untreated). The commentary discusses the use of protocol-based management of chronic medical conditions, the inclusion of interprofessional care teams to coordinate management, and the importance of inter-team communication to identify issues and prevent poor outcomes.
WebM&M Cases
Kristine Chin, PharmD, Van Chau, PharmD, Hannah Spero, MSN, APRN, and Jessamyn Phillips, DNP |
This case involves a 65-year-old woman with ongoing nausea and vomiting after an uncomplicated hernia repair who was mistakenly prescribed topiramate (brand name Topamax, an anticonvulsant and nerve pain medication) instead of trimethobenzamide (brand name Tigan, an antiemetic) by the outpatient pharmacy. The commentary uses the Swiss Cheese Model to discuss the safety challenges of “look-alike, sound-alike” (LASA) medications, the importance of phyiscians employing “soft” skills during medication dispensing, and how medication administration errors can occur in outpatient pharmacy settings, despite multiple opportunities for cross-verification.
WebM&M Cases
Spotlight Case
Richard P. Dutton, MD MBA |
A 40-year-old man with multiple comorbidities, including severe aortic stenosis, was admitted for a pathologic pelvic fracture (secondary to osteoporosis) after a fall. During the hospitalization, efforts at mobilization led to a second fracture of the left femoral neck The case describes deviations in the plan for management of anesthesia and postoperative care which ultimately contributed to the patient’s death. The commentary discusses the importance of multidisciplinary planning for frail patients, the contributors to, and consequences of, deviating from these plans, and the use of triggers, early warning systems, and rapid response teams to identify and respond to early signs of decompensation.
This Month’s Perspectives
Interview
Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is the Senior Vice President of Integrated and Acute Care Services and the Chief Nursing Officer (CNO) at Parrish Medical Center in Titusville, Florida. We spoke with him about his experiences with the concept of safety across the board at his medical center.
Perspective
This piece discusses the concept of Safety Across the Board and reviews the three key components necessary for successful implementation in a healthcare organization: culture, strong safety processes, and engagement.
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